A technique for the management of posttraumatic aniridia and aphakia

Aim: To describe our results with HumanOptics IOL-ArtificialIris complex in post traumatic aphakia and aniridia. Methods: Retrospective, single-surgeon chart review of cases in which aniridia and aphakia were corrected using HumanOptics IOL-ArtificialIris complex sutured to the sclera with Gore-Tex® sutures and coupled with the Akreos® IOL (Bausch&Lomb). Results: The authors present four cases of ocular trauma with globe rupture. For every patient, posterior vitrectomy was done and an artificial iris-lens diaphragm was sutured to the sclera. All patients had a good functional and cosmetic outcome. Conclusions: Surgical implantation of the HumanOptics IOL-ArtificialIris complex coupled with the Akreos® IOL was successful in alleviating post-trauma aphakia and aniridia related visual impairment.

Introduction and fixation loops [2]. There are now more modern devices such as the Morcher iris IOL implants and the With its ability to control the amount of light that reaches Ophtec BV. The first offers correction for both aniridia the retina through pupillary diameter changes, the iris and aphakia, however it requires a large corneal incision has a paramount role in vision quality. Some conditions, (150-180º) and the iris is pure black which cosmetically either congenital or acquired, can contribute to complete is not ideal. As for the second device, although it comes or partial iris absence with serious consequences to vi-in three colours, it also requires a large incision and still sion. These include diminished visual acuity, spherical has a poor disguised artificial appearance when comaberrations, glare, photophobia, contrast perception and pared to the fellow eye. changes in depth of focus. There is also an important In 2007, the HumanOptics CustomFlex ® ArtificialIris cosmetic factor [1], [2], [3]. Nowadays there are several prosthesis became available. It consists of a foldable surgical and non-surgical options to correct iris defects, custom made hydrophobic silicone diaphragm, with the such as cosmetic contact lenses, corneal tattooing, in-option of an integrated polymer fiber meshwork to which trastromal corneal implants, microtying suture techniques, an IOL can be sutured to correct both aniridia and aphakia amongst others. For defects so large that they are im- [1], [2], [3]. The authors present a retrospective, singlepossible to correct surgically, there is the option of pros-surgeon chart review of four cases in which aniridia and thetic iris implants [1]. aphakia were corrected with an IOL-artificial iris complex Used for the first time in 1964 by Peter Choyce, iris sutured to the sclera using Gore-Tex ® sutures. All patients prostheses have undergone major changes. Presently, underwent complete ophthalmic examination both before there are several models available, such as IOL-iris and after the procedure. combinations, capsular tension ring based prosthetic iris devices and foldable custom artificial iris [1]. As far as the IOL-iris prostheses combinations are concerned, the first models consisted of a central optic, a 10 mm PMMA diaphragm with a black outer ring, curved haptics, 1/4 GMS Ophthalmology Cases 2020, Vol. 10, ISSN 2193-1496 Case Report

Case descriptions
All patients included in this review (Table 1) had suffered ocular trauma with globe rupture, iris disinsertion, and traumatic cataract (Figure 1). Mean age was 54.5 years (min. 45, max. 63), with three men and one woman included in this case series. There were no known previous ophthalmological problems. Visual acuity in the preoperative period was hand motion or less in all patients. 25-gauge pars plana vitrectomy was done in all patients. Patient 2 also had phacoemulsification done for partial spontaneous cataract resorption. In all cases, a previously measured and cut CustomFlex ® ArtificialIris prosthesis (Human Optics) and an Akreos ® IOL (Bausch&Lomb) was folded and dialed into place in the ciliary sulcus, through Figure 3: Surgical procedure with implantation of the Akreos ® the superior 3.75 mm limbal-based corneal wound. The

Discussion
Trauma to the eye with subsequent aniridia and aphakia not only has functional consequences with poor quality of vision, but also the aesthetic component can be a constant reminder of a traumatic event [1], [2]. The authors present a refined approach to this condition, using a custom-made artificial iris, to match the patient's original iris color, and to which an adequate IOL was sutured. The flexible and foldable artificial iris has a diameter of 12.8 mm and can be easily cut with scissors or with a trephine and then inserted through small incisions into the ciliary sulcus of a pseudophakic or aphakic eye [1], [3]. The results showed not only a remarkable aesthetic result (Figure 4) but also a significant improvement in visual acuity, like in other series [3]. Six months after surgery, BCVA was between 20/150 (patient 1) and 20/50 (patient 4). Vitreous hemorrhage and hyphema were intraoperative complications in patients 2 and 3, respectively. Secondary glaucoma was the only late postoperative complication and it happened in one patient (patient 2). No evidence of suture erosion or breakage, wound leak or infectious endophthalmitis was observed in either case. Despite these very positive results, one of the four cases reviewed developed late glaucoma with requiring ongoing medication after surgery. Some authors associate late complications such as the latter as well as darkening of the iris tissue and the need for consecutive anterior segment surgery, with the presence of the integrated polymer fiber meshwork present in these artificial iris, presumably due to their sharp endings [3].

Conclusions
In trauma-related aphakia and partial or complete iris defect, surgical implantation of the HumanOptics IOL-ArtificialIris complex coupled with the Akreos ® IOL appears to be a satisfactory method for improvement of both visual function and cosmetic issues. However, further experience and longer follow-up times are needed in order to best determine the true incidence of long term complications with this method and how to avoid them [1], [3].

Conference presentation
Best poster presentation at the 3 rd European Meeting of Young Ophthalmologists, July 13-14, 2018 in Cracow, Poland.